MEDICARE: NORTHEAST GEORGIA SURGERY CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1265037600
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST GEORGIA SURGERY CENTER

Provider Business Mailing Address
First Line	:	601 BROAD ST SE STE E
Second Line	:
City	:	GAINESVILLE
State	:	GA
Zip	:	30501-3718
Country	:	US
Telephone Number	:	678-971-4227
Fax Number	:	678-971-4238

Provider Business Practice Location Address
First Line	:	601 BROAD ST SE STE E
Second Line	:
City	:	GAINESVILLE
State	:	GA
Zip	:	30501-3718
Country	:	US
Telephone Number	:	678-971-4227
Fax Number	:	678-971-4238

Authorized Official
Title or Position	:	OWNER
Name	:	ANKUR PATEL
Credential	:
Telephone Number	:	678-971-4227

Provider Enumeration Date	:	12/03/2020
Last Update Date	:	12/03/2020

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